standard operating procedure for medical … 9001-2015/sop/29 sop medical department... ·...

Document Ref.: Issue Date:

CU/SOP/MEDD/29 30th September, 2017

Issue No.: Revision No.:

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Document Title:

STANDARD OPERATING PROCEDURE FOR MEDICAL SERVICES MANAGEMENT

Controlled Copy: Circulation Authorized by the Management Representative. of 20

CHUKA UNIVERSITY

Standard Operating Procedure

For

Medical Services Management

CU/SOP/MEDD/29

Document Review Sheet

The signatures below certify that this Standard Operating Procedure has been reviewed and accepted,

and demonstrate that the signatories are aware of all the requirements contained herein and are

committed to ensuring their provision.

Action Name & Signature Position Date

Prepared by Caroline Gatwiri

Kithinji

CLINICAL OFFICER 31.8.2017

Reviewed by Prof. D. K. Isutsa

DEPUTY VICE-CHANCELLOR (ARSA)/MR 30.9.2017

Approved by Prof. E. N. Njoka VICE-CHANCELLOR 30.9.2017




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CONTENTS

COVER PAGE..................................................................................................................... 1

DOCUMENT REVIEW SHEET……………………………………………………… 1

CONTENTS........................................................................................................................... 2

1.0. AMENDMENT RECORD ………………………………………………………… 3

2.0. GENERAL…………………………………………………………………………. 4

2.1 Purpose……………………………………………………….............................. 4

2.2 Scope…………………………………………………………............................. 4

2.3 References………………………………………………………......................... 4

2.4 Abbreviations ………………………………………………................................ 4

2.5 Definitions......................................................................................................... 5

2.6 Responsibility......................................................................................................... 5

3.0. ADMINISTRATIVE STRUCTURE……………………………………….……… 5

4.0. PROCESSES……………………………………………………………….............. 6

4.1 Overview………………………………………………………………………….. 6

4.2 Process for patients’/clients registration and flow……………………………… 6

4.3 Process for consultation ………………………………………………………….. 7

4.4 Process for administration of laboratory examination and diagnosis……………. 8

4.5 Process for requisition of medical equipment, Pharmaceuticals and lab reagents 9

4.6 Process for administration of pharmaceuticals and injection ……………………. 9

5.0. RECORDS………………………………………………………………………….. 10

6.0. KEY PERFORMANCE INDICATORS/OBJECTIVES……………………….. 11

6.1. Key Performance Indicators……………………………………………………… 11

6.2. Quality Objectives………………………………………………………………… 11

RISK AND OPPORTUNITIES REGISTER……………………………………… 15

APPENDICES: PROCESS MAPS................................................................................ 17




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1.0 AMENDMENT RECORD

This Standard Operating Procedure is reviewed regularly to ensure relevance to the systems and

process that it defines. A record of contextual additions or omissions is given below.

Amendment Record Sheet Amendment

Date

Issue

No.

Revision

No.

Page

No.

Subject of Review

/Modification

Revised

By

Approved By




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2.0 GENERAL

2.1 Purpose

The purpose of this procedure is to ensure that all medical activities are managed effectively to

ensure compliance with the International Standard and the Ministries’ of Medical Services, Public

Health & Sanitation, WHO procedures and guidelines.

2.2 Scope

This procedure applies to and defines all the activities carried out by the Medical Department.

2.3 References

(i) CU Charter, 2013

(ii) CU Statutes, 2014

(iii) CU Strategic Plan, 2017-2022

(iv) ISO 9001:2015 Standard Clauses 4 to 10

(v) CU ISO Quality Management System Manual, 2017

(vi) CU Students’ Information Handbook (Current)

(vii) Advanced First Aid & Emergency Care (Red Cross)

(viii) AMREF Manual

(ix) Clinical Methods Manual by Hutchinson

(x) Drug index for Health Care Practitioners

(xi) Live Saver International First Aid Course (St. John’s Ambulance)

(xii) Nursing Council of Kenya Procedure Manual

(xiii) VCT Guide

(xiv) WHO Manual

2.4 Abbreviations

AIDS = Acquired Immune Deficiency Syndrome

AMREF = African Medical Research Foundation

COD = Chairperson of Department

CMO = Chief Medical Officer

HCT = HIV Counseling and Testing

HIV = Human Immune-Deficiency Virus

HOD = Head of Department

HRIO = Health Records Information Officer

KRCHN = Kenya Registered Community Health Nurse

MLT = Medical Lab Technologist

RCO = Registered Clinical Officer

SOPs = Standard Operating Procedures

VCT = Voluntary Counseling and Testing

WHO = World Health Organization

VC = Vice-Chancellor




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2.5 Definitions

SSP Students: Students who do not benefit fully from government fees subsidy

KUCCPS Students: Government Sponsored Students-Students who are admitted by Kenya

universities and colleges’ placement service and benefit from Government fees subsidy

2.6 Responsibility

The Chief Medical Officer has the primary responsibility of ensuring that this procedure is

implemented and remains adequate for its intended purpose. The Chief Medical Officer also has the

primary responsibility for providing the information from which the documentation for the medical

processes can be compiled and for initiating action to keep them up to date. All departmental staff

are responsible for implementing and ensuring that this procedure is followed.

3.0 ADMINISTRATIVE STRUCTURE

Medical Department is one of the Departments within the University. The current administrative

structure for the Department is as shown below:

Nursing Officers

Clinical Officers

Administrative

Assistant

Health Records Information

Officer (Vacant)

Deputy Vice-Chancellor (Administration, Finance, Planning, & Development)

Vice-Chancellor /CEO

Chief Medical Officer

(Vacant)

Pharmacist Accountant

(Vacant)

Support staff

(Clerks/Messengers/Cleaners




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4.0 PROCESSES

4.1 Overview

The core activities of the Department include:

(i) Clerking and examination of patients and keeping medical records up-to-date

(ii) Evaluation/monitoring progress of patients on treatment

(iii) Generating income through medical charges from staff, Ndagani Secondary School

students and staff and SSP students

(iv) Offering preventive and curative services

(v) Laboratory diagnosis

(vi) Prescribing and dispensing of drugs

(vii) Requisition of medical drugs and equipment

(viii) Offering medical counseling to patients and clients with special needs, including

VCT/HCT and referring them

4.2 Process for Clients Registration and Flow

4.2.1 Source

Patients

4.2.2 Required inputs

Medical biodata and personal details forms

Passports

Client and Outpatient registers

Clerk

4.2.3 Expected outputs

Personal file

4.2.4 Receivers

Patients

4.2.5 Process Details

No. Description Output Responsibility

1. During registration or admission of clients in

the university i.e. S.S.P, staff and KUCCPS

students bring their completed medical biodata

forms signed by a recognized medical

representative or practitioner.

Client biodata Clerk/HRIO

2. The Medical biodata forms and personal

details form containing passport photos from

the clients are pinned together

Assembly of

biodata documents

Clerk

3. The HRIO /clerk opens a personal file for each

client bearing the official names and

payroll/registration number/

Personal file HRIO/clerk




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4. When the client is ill he/she presents the

identification card for file retrieval

Treatment sheet HRIO/clerk

5. t The file is taken to the clinician in the

consultation room

Consultation HRIO/clerk

4.3. Process for Consultation

4.3.1 Source

Patients; CU/SOP/DVCF/02; CU/SOP/VCIM/01

4.3.2 Required input

Clinician

Personal file/Patients history

Lab results

Diagnostic equipment


Prescription

Laboratory request

Referral letter

Sick off form

Counseling report

4.3.4 Receivers




1. The clinician takes the patient’s particulars,

notes the presenting complaints, takes history of

presenting illness indicating the duration of thee

illness and examines the patient.

Diagnosis Clinician

2. Depending on the clinical diagnosis the patient

is managed or referred elsewhere for serious

cases and a referral letter is written.

Referral letter Clinician

3. Depending on the patient’s condition, the

clinician sends the patient to the laboratory with

a lab request form or a prescription form to the

pharmacy for cases not referred

Laboratory

request form

Prescription form

Sick off

HRIO/clerk

4. The patient sent to the laboratory returns the lab

results to the clinician after investigations

Diagnosis Laboratory

technologist

5. The clinician prescribes the drugs to the client Prescription form Clinician




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4.4 Process for Laboratory Examination and Diagnosis

4.4.1 Source

Patients


Client

Medical laboratory technologist

Specimen

Laboratory register

Laboratory equipment/machines

Lab reagents


Laboratory results

Laboratory reports

4.4.4 Receivers

Patients



1. The patient presents the laboratory request

form to the MLT, who explains the

procedure/type of specimen to be collected,

labels the specimen containers and the

requisition form

Specimen/ sample Medical

Laboratory

Technologist

2. The investigation are then charged and patient

is issued with a receipt by the accounts clerk

Receipt Cashier

3. The specimen is then collected by the MLT

who instructs the patient to wait for the results

depending on the duration of the analysis

Analyzed Results Medical

Laboratory

Technologist

4. The MLT analyses specimen following

instructions in WHO and AMREF Manuals

(a) The equipment used in testing include a

Haematology Analyser-Medonic Series

Calibrated annually by Medipharm East

African Ltd.

(b) The others are Centrifuge 90-2, Incubator,

Microscope, Armblood Digital and

Mercury (Sphigmimanometer) Blood

Pressure Monitors, and Stethoscope

Monitor, all Calibrated every six (6)

months by Collinbet Electech Mechanical

Quality results Medical

Laboratory

Technologist




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Engineering accredited by the Chuka

District Hospital licensed by the Ministry

of Medical Service

5. The MLT records the results in the laboratory

register and request form which is given back

to the patient who then takes it to the

consultation room.

Laboratory results Medical

Laboratory

Technologist

4.5 Process for Requisition of Medical Equipment, Pharmaceuticals and Lab Reagents

4.5.1 Source



Approved letter/Bin cards

MLT/Pharmacist/in charge medical dept

Stores requisition book

Goods and services requisition book


Delivery of requested commodities

4.5.3 Receivers




1. Drugs/reagents out of stock are identified from

the bin card and listed by the /MLT

Pharmaceutical technologist

List of items MLT/pharmacist

2. The request for approval letter is raised Approved letter MLT/pharmacist

HOD,

DVC(AFPD)

3. The approval letter is taken to the procurement

office for purchase and the goods and services

requisition note is written CU/SOP/PROD/25).

LPO Procurement

officer, VC

4. Procurement procedure is followed Delivery of goods PO

Supplier

4.6 Process for Administration of Pharmaceuticals and Injections

4.6.1 Source


Bin cards




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Pharmacist/nurse

Client

Prescription form

Pharmaceuticals


Injection administration

Dispensed drugs

4.6.4 Receivers



Description Output Responsibility

Patient presents prescription to the

Pharmaceutical technologist for verification

and preparation

Prescription Pharmaceutical

Technologist

2. Pharmaceutical technologist prepares the

medication as per the prescription and

charges appropriately where applicable

Medical charge Pharmaceutical

Technologist

3. Pharmaceutical technologist dispenses the

drugs prescribed with instructions on use.

Drugs and drug use

counseling

Pharmaceutical

Technologist

4. The patient is notified by the Pharmaceutical

technologist the injections to administered

and directs him/her to the injection room

Injection instructions Pharmaceutical

Technologist

5. The procedure for injection is explained to

the patient and the injection is administered

(a) Sharps are taken to Chuka District

Hospital for incineration while solid waste is

burnt in a deep compost pit.

(b)Quality control is performed daily.

Injection Nurse

5.0 RECORDS

(1) Bin cards

(2) Equipment calibration contracts and verification results

(3) HCT register MOH 362

(4) Laboratory register MOH 240

(5) Monthly Report

(6) Client attendance register

(7) Outpatient register, over 5years MOH204B

(8) Outpatient over 5 yr tally sheet MOH701B

(9) Outpatient over yr summary 705B

(10) Patient files




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(11) Petty cash book

(12) Receipt books

(13) Revenue collection register

(14) Stock taking form

(15) TB treatment register

(16) Weekly epidemic monitoring register

(17) Consumption data report MOH 643

6.0 KEY PERFORMANCE INDICATORS AND OBJECTIVES

6.1 Indicators

(i) Number of laboratory tests done

(ii) Number of drugs dispensed

(iii) Number of patients seen

(iv) Number of complains/compliments registered.

6.2 Quality Objectives

Linked Strategic Objectives

SO 3: Enhancement of Academic Competitiveness of the University

SO 24: Development and Projection of a Positive Image of the University

SO 25: Maintenance and Improvement of Quality Assurance

SO 27: Compliance with Statutory Requirements

1. Quality Objective (state the objective)

To reduce waiting time of patients by at least 10 minutes at the waiting bay.

Strategy (Actions/Activities required to achieve the objective

Training of reception staff on proper record keeping

Increase the no of clerks/HRIO at the reception

Treat patient on first come first served

RESPONSIBILITY RESOURCES

REQUIRED

TIMELINE MEASURE OF SUCCESS

(KPIs)

management

Human resource

Human, facilitators

finances

facility

writing materials

Annually No. of training sessions

conducted

No. of staff deployed

notes

attendance list

Review dates: Quarterly




SO 25: Maintenance and Improvement of Quality Assurance

SO 27: Compliance with Statutory Requirements


To disseminate health education information on HIV/AIDS and other health issues to at least 30

patients twice per week.




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Conducting health talk to patients on waiting bay twice per week


REQUIRED


(KPIs)

In-charge medical IEC materials

Models

Newsprint,

felt pen

facilities

Twice per

week

No. of students educated

No. of IEC material issued

Review dates: Weekly




SO 30: Development of Motivated Staff

SO 34: Production of Holistic Graduates


To provide health services to at least 50 patients per day to achieve quality education


Proper clinical diagnosis, accurate analyzing of lab results and rational drug use and counselling


REQUIRED


(KPIs)

Clinicians

Nurses

Lab tech

pharm tech

Pharmaceuticals,

Reagents

Diagnostic

Equipment/machines

Facility

OPD register

Daily No. of clients treated

Review dates: Daily




SO 30: Development of Motivated Staff

SO 31: Enhancement of Gender and Affirmative Action Compliance

SO 34: Production of Holistic Graduates


Improve reproductive health services by distribution of 20,000 condoms per quarter to clients


Allocation of staff to distribute condoms

Creating awareness through social media, health education


REQUIRED


(KPIs)




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In-charge medical IEC materials

Models

Newsprint, felt pen

Facilities

Personnel

Condoms ie male

female

Condom dispensers

Twice per

week

No. of students educated

No. of IECs material issued

No. of condoms distributed

Review dates: Weekly

Risk Identification Table

Department: MEDICAL

Project /Process Name: Laboratory diagnosis and examinations

SN Risk Source

(How can the risk occur)

Impact

(What is the impact of the

risk occurring)

1 Accidental pricking, During sample collection Contracting diseases

2 Inhaling of aerosols Sample collection, analyzing

of samples, cultures

Contracting diseases

3 Fire due to inflammable

chemicals

When heating/fixing the

samples

Burns

4 Loss of cash Handling of cash by many

people

Loss of revenue

5. impersonation SSP using jab students I.D Loss of revenue

6 Stock out Delay in procurement

procedures

Lack of lab reagents

Project /Process Name: Process for consultation

1 Communicable diseases e.g

TB

Patient coughing without

observing cough etiquette

Morbidity and low

productivity

2 Harassment by client

Patient digitating his

management

Psychological trauma and

demoralisation

3 Wrong diagnosis Patient giving wrong history

Wrong treatment and

disease progression

4 Irrational drug use Lack of training on current

treatment guidelines

Wastage of resources, drug

resistant

Project /Process Name: Process for requisition of medical equipment, pharmaceuticals and

lab reagents

1 Stock out Delay on procurement

procedures

Lack of drugs and lab

reagents

Project /Process Name: Process for administration of pharmaceuticals and injections

1 Contracting communicable

diseases e.g. TB

Patient coughing Morbidity and low

productivity




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2 Loss of cash Handling of cash by many

people

Loss of revenue

3 Impersonation SSP using KUCCPS student

I.D for treatment

Loss of revenue for the

university

4 Accidental needle prick When injecting an

uncooperative patient

Morbidity and low

productivity

Project /Process Name: registration of patients and flow of clients at the reception

1 impersonation SSP students using KUCCPS

I.D to seek treatment

Loss of revenue

2 Communicable diseases e.g.

TB

Patient coughing without

etiquette

Morbidity and low

productivity

3 Harassment by clients Student in a hurry

Students coming in large

groups after class and

demanding to be attended

immediately

Psychological trauma

4 Misplacing of files Lack of enough shelves thus

crowding of files making

retrieval difficult

Delay in attendance of

patients

5 Inaccurate data entry Untrained reception staff Inaccurate reports and

documentations




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RISK AND OPPORTUNITIES REGISTER Note for monitoring, the responses are: What = risk described. Why = prevent/correct consequence. How = mitigations/controls. Who = risk owner.

Risk name/description Risk Consequences

Raw Risk Mitigations/controls

(Opportunities source) Risk Owner Monitoring Likelihood

(L)

Consequence

(C)

Raw Risk

(L x C)

Acquiring

communicable

diseases like PTB,

MDR, HIV/AIDS,

hepatitis b

Absenteeism of employees

Isolation

Disease spread to other

patients, family members

and staff

Cost implication

2 3 6 Sensitization on infection

prevention and control

methods

Vaccination

Medical checkups

Medical department

staff

In-charge medical

Top management

Continuous

Loss of cash Loss of revenue 1 2 2 Deployment of cashier Pharmaceutical

technologist

Laboratory

technologist

Staff in medical

Continuous

Impersonation by SSP

students

Loss of revenue 2 2 4 Verification of student id

and national id and

personal details form

during file retrieval

HRIO/clerk Continuous

Medical accidents e.g.

needle pricks, blood

splash, contact with

contaminated blood

Acquire HIV/AIDS

infection and hepatitis b

2 3 6 Wearing of protective

gloves

Training on the right

precautions to take

Use of post exposure

prophylaxis

Vaccination

Clinicians and

laboratory

technologists

Daily

Accident

occurrence

register

Threats/intimidation

by clients/sexual

harassment

Fear leading to in

efficiency

Reduced output

Psychological or physical

trauma

1 2 2 Signing of rules and

regulation at the time of

admission

Issuance of student hand

booklets

Deployment of security

personnel around the

facility

Student to be escorted by

In-charge medical

Security In-charge

Dean of Students

Office

During

admission of

students

Continuous




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security officers at night

Professional

negligence

Harm or death to patient 1 3 3 Adherence to professional

code of conduct and

ethics

All medical staff Continuous

Dysfunction of first

aid equipment in the

ambulance

Patient disability/death 1 3 3 Renewing or replacement

of first aid equipment and

drugs

In-charge medical

Senior management

Continuous

Pharmaceuticals/reage

nts stockout

Lack of

pharmaceuticals/reagents

2 2 4 Efficiency in procurement P.O Quarterly

Inaccurate data entry

Inaccurate reports and

documentation

2 2 4 Training of reception staff Top management Monthly

Misplacing of clients

file

Delay in treatment 2 2 4 Additional of more

shelves

Top management Continuous

Fire Burning of the facility,

staff

1 3 3 Fire extinguishers Proper

storage of flammables

Security Officer Continuous

Irrational drug use Drug resistant 2 2 4 Continuous medical

education on current

treatment guidelines and

practices

Clinical Officers

Nurses

Continuous

Wrong diagnosis Wrong treatment

Disease progression and

drug resistant

2 3 6 Proper history taking and

investigations

Clinical Officers

Nurses

Continuous




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APPENDICES: PROCESS MAPS

i. Patient/client registration and flow

RESPONSIBILITY ACTION

Patient

Arrival at dispensary

HRIO

(HEALTH RECORDS

INFORMATION

OFFICER/clerk)

During registration clients i.e. SSP, staff and KUCCPS students bring

their completed medical biodata forms signed by a recognized medical

representative or practitioner.

The Medical biodata and personal details forms containing passport

photos from the clients are pinned together

The clerk/HRIO opens a medical file for each client/student.

CLEANER/

SUB-ORDINATE STAFF

Daily decontamination of working benches, tables and chairs, cleaning

of the floors & windows before patients start flowing.

HRIO (HEALTH RECORDS

INFORMATION OFFICER

/CLERK)

The patient is received at the customer care desk in the waiting bay by

the HRIO/clerk.

Each patient presents identification to the HRIO for file retrieval. The

HRIO /clerk writes patients particulars in the file and registers him/her

in the outpatient register.

The HRIO/clerk then forwards the file to the consultation room.

CLINICIAN Taking of the patients history of illness, examines, investigates and

makes the diagnosis/impression (refer to clinical methods manual)

MEDICAL OFFICER

CLINICAL OFFICER

Depending on the clinical diagnosis patient is managed or referred to a

counselor, VCT, or referred to CDH for serious cases.

Cases handled in dispensary are sent to the cash office for payment.

CASHIER The patient upon presenting the prescriptions and or requisition form is

costed, charged and receipted for the service accordingly using a receipt

in triplicate.

The accounts clerk then records the transaction

TECHNOLOGIST

PATIENT /CLIENT

Upon payment patient proceeds to the pharmacy, injection room or lab

Cases from the lab bring back their results and are prescribed with

drugs which they pay for at the cash office or are counseled by the

caregivers accordingly.

ii. consultation




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CLINICIAN Taking of the patients history of illness, examines, investigates and

makes the diagnosis/impression (refer to clinical methods manual)

MEDICAL OFFICER

CLINICAL OFFICER

Depending on the clinical diagnosis patient is managed or referred to a

counselor, VCT, or referred for serious cases.

A sick off is given for some cases

CASHIER Depending on the patient’s condition, the clinician sends the

patient to the laboratory with a lab request form or a prescription

form to the pharmacy for cases not referred NURSES

CLINICAL OFFICER

LAB TECH

PHARM TECH

Upon payment patient proceeds to the pharmacy, injection room or lab

Cases from the lab bring back their results and are prescribed with

drugs which they pay for at the cash office or are counseled by the

caregivers accordingly.

(ii) Laboratory examination and diagnosis


PATIENT /CLIENT

Reporting to room

PATIENT /CLIENT Presenting the lab requisition sheet to the MLT who explains the procedure/the

type of specimen to be collected, labels the specimen containers and the

requisition form.

MEDICAL LABORATORY

TECHNICIAN/

TECHNOLOGIST

Collecting specimen by the MLT and instructs the patient to wait for the results

depending on the duration of the analysis.

Analysing of the specimen following SOPs (WHO and AMREF manuals

Recording the results in the laboratory register and request form which is given

back to the patient who then takes it to the consultation room.

(iii) Injection and pharmaceuticals administration





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PHARM TECH

The patient presents the prescription for verification and preparation

PHARM TECH

The prescription is prepared for medication as per the prescription and

charged appropriately

PHARM TECH

Pharmaceutical technologist dispenses the drugs prescribed with instructions

pertaining to use.

PHARM TECH

The patient is notified by the of Pharmaceutical technologistt he injections to

administered and directs him/her to the injection room

NURSING OFFICER The nurse explains the procedure to the patient, prepares and administers the

injection and updates stocks records.(refer procedure manual for nurses)

Sharps are taken to CDH for incineration while solid waste is burnt in a deep

compost pit. Quality control is performed daily

(iv). Requisition of pharmaceuticals lab reagents medical equipment


Pharmaceutical

technologist /MLT

Drugs/reagents out of stock are identified from the bincard and listed by the

MLT/ Pharmaceutical technologist MLT/PHARM TECH

HOD,DVC(AFP&D)

Request for approval is raised

The approval letter is taken to the procurement office for purchase and

the goods and services requisition note is written CU/SOP/PROD/25).

P.O Procurement procedure follows

(v) Voluntary Counselling and Testing




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VCT HIV Prevention Intervention Components

HIV Negative and Positive Sessions

Introduction and Orientation to Session (3 min)

HIV test preparation (3 min)

AS THE TEST RUNS;

Asses risk & explore options for reducing risk

(15 min)

HIV negative test result

counseling (2 min)

Negotiate Risk Reduction Plan

(2 min)

Discuss risk reduction issues & identify sources of support

(2 min)

Negotiate disclosure and partner referral (2 min)

Negotiate Disclosure

(2 min)

Total time for the whole session is 30 minutes

HIV positive test result counseling

(2 min)

Conduct Test (3 min)

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